Reliability of Leukocytosis in Diagnosing Acute Appendicitis.

Acute appendicitis is a frequently encountered surgical disease. Detection is difficult even with imaging and blood investigations. Total leukocyte count is a promising investigation. Its role in the confirmation of acute appendicitis is investigated and analysed in the present study. MethodsPatients having acute appendicitis treated by surgical intervention (appendicectomy) were included in the study. The leukocyte count measured before surgery was compared with histopathology findings of the appendix. Parameters of diagnostic accuracy of leukocytosis were measured by standard formulae. ResultsThe sensitivity and specificity of leucocytosis were found to be 76 percent and 12.5 percent respectively. The positive predictive value and negative predictive value of leucocytosis was 65 percent and 20 percent respectively. Overall diagnostic accuracy was 56 percent. The results were compared with histopathology of acute appendicitis. ConclusionsLeukocytosis is a helpful investigation to support the diagnosis of acute appendicitis.

Alvarado score and computerized tomography scan as impact indicator in intervening negative appendectomy rate

Background: The objective of this study is to study the impact of combined use of Alvarado score and computed tomography (CT) scan on negative appendectomy rate.Methods: This prospective observational study comprising of patients presenting with clinical features of appendicitis admitted to department of general surgery, VIMSAR, Burla from November 2017 to October 2019, where Alvarado score and ultrasonography (USG) findings are mismatching each other. Alvarado scores calculated and categorized in 2 groups as negative (score <4) and positive (score ≥4). These patients were also subjected to USG and categorized as negative (USG -ve) and positive (USG +ve). Those patients having discrepancy in both the findings were subjected to CT scan. On histopathological examination, inflamed appendix in 63 (97%) patients and non-inflamed in 2 (3%). Rest patients were either discharged (both -ve) or operated (both +ve). Results: Total 84 patients showed discrepancy between Alvarado score and USG findings and are subjected to CT scan abdomen and pelvis. CT scan was positive for appendicitis in 65 cases (where appendectomy done) and negative for appendicitis in 19 cases (where the diagnosis is different). patient. Thus, negative appendectomy (NAR) is 3% in this study.Conclusions: Alvarado score and ultrasonography could not be used as absolute tool in doubtful and equivocal cases, where combined use of CT scan with Alvarado score and USG has definitely has an edge by diagnosing the differentials and reducing NAR followed by reduction in cost and length of hospital stay.

Role of clinical scoring system and imaging in acute appendicitis in adults: a review of literature

@#Introduction: Ultrasound is widely available, easy-to-use and less expensive than most other imaging methods. It is widely used as a non-invasive method to diagnose acute appendicitis; however, its efficiency still remains questionable, especially when compared to costlier and invasive methods such as computed tomography. Methods: An exploratory review of past literatures on the usage of ultrasound technique in the diagnosis of acute appendicitis in adult patients, and the role of other imaging techniques were undertaken for the study. Results: The gold standard for the diagnosis of acute appendicitis still remains a histopathological confirmation after appendectomy. The study further shows imaging has high diagnostic accuracy in the diagnosis of acute appendicitis with low rate of negative appendectomy (<10%). Multiple reasons are identified, including the introduction of computed tomography imaging especially in those patients where ultrasound was unequivocal, more education on imaging which leads to better operator skill or improved performances of machines. Conclusion: Imaging undoubtedly plays an important role in the diagnosis of acute appendicitis with ultrasound remaining the first-line method in patients referred with clinically suspected acute appendicitis. Nevertheless, those with borderline ultrasound findings or unable to visualize appendix on ultrasound with highly suspicious sign and symptoms were offered other imaging modalities such as CT scan. Recommendation: It is recommended that the managing team balance the risk of radiation exposure, risk of delay in urgent operation and risk of perforation prior to a decision.

Clinical Relevance of Modified Alvarado Score in Acute Appendicitis in Present Scenario

Introduction: Appendix is surely, the most commonlyharvested organ of the body. On looking up the literature,we found, that the negative appendectomy rates have beenconsistently maintained all through these years. Negativeappendectomy not only increases economic burden on healthcare facilities of a developing country like India, but alsohas a negative impact on the overall health of the patient.The following study was therefore, taken up to evaluate thediagnostic accuracy of the Modified Alvarado scoring systemand its ultimate effect on mortality and morbidity of the patient.Though this is an old score, but we restudied it, to revalidateas well as to promote the use of this simple, economicaland objective clinical score which actually uses establishedclinical methods, important for residents training program, toreach the diagnosis instead of the costly radiological methods.Material and methods: 50 patients presenting with thelower quadrant abdominal pain and fulfilling the inclusioncriteria were selected randomly and included in the study.Modified Alvarado Score was calculated for each one ofthem. Confirmation of the diagnosis was done after thehistopathological examination of appendix.Results: Modified Alvarado Score >7 was found in 80% (i.e.82.75% of males and 76.19% of females) of patients withappendicitis. In addition to these findings, we also got exactinformation about the age and sex distribution along withthe most common presenting complaint, the postoperativecomplications and the need for post operative stay inappendicitis patients.Conclusion: Modified Alvarado Score is a fast, simple,noninvasive, repeatable and highly economical score. Whenapplied purposefully and objectively, it can prevent delayin surgeries and hence complications as well as can reducenegative appendectomies.

Apendicetomía no terapéutica: revisión de 1 año en el Centro Hospitalario Pereira Rossell, Montevideo, Uruguay / Non-therapeutic appendectomy: 1-year review at the Pereira Rossell Hospital Center, Montevideo, Uruguay / Apendicectomia não terapêutica: revisão de 1 ano no Centro Hospitalar Pereira Rossell, Montevidéu, Uruguai

Objetivos: La apendicitis aguda es una de las patologías quirúrgicas más frecuentes en pediatría y la apendicectomía un procedimiento históricamente probado para su tratamiento. Sin embargo, se ha llamado la atención sobre la morbilidad y costos que implican los casos de apendicectomías no terapéuticas (ANT). Realizamos un estudio para determinar la proporción de ANT en nuestro hospital, analizar sus características y plantear hipótesis de trabajo que nos permitan disminuir su incidencia. Métodos: Se realizó un análisis retrospectivo incluyendo todos los pacientes que fueron intervenidos quirúrgicamente desde el 1/1/13 hasta el 31/12/13 con diagnóstico clínico presuntivo de apendicitis aguda, en el Hospital Pediátrico del Centro Hospitalario Pereira Rossell. Se analizaron la edad, el sexo, la vía de abordaje, los hallazgos intra-operatorios, el diagnóstico anátomo-patológico y el uso y los resultados del hemograma y la ecografía. Resultados: En el período mencionado se realizaron 287 apendicectomías en pacientes con diagnóstico de apendicitis aguda, de los cuales 146 (50,87%) fueron operados por medio de un abordaje convencional y 141 (49,13%) por abordaje laparoscópico. El índice de ANT fue de 10,1% siendo similares las tasas para ambas vías de abordaje (10,27% convencional vs 9,92% laparoscópica). Por otra parte, se evidenció una mayor incidencia de ANT en el sexo femenino (16,6% vs 5,8%). Respecto a la franja etaria, la tasa de ANT fue mayor entre los pacientes de 11-15 años(12,19%), mientras que para las edades comprendidas entre 6-10 años fue de 8,08% y para los pacientes de 0-5 años fue de 4,16%. De los 29 pacientes que presentaron apéndice sano, 12 presentaban adenitis mesentérica, una paciente presentaba una rotura folicular y una paciente presentaba una peritonitis de causa médica. En 15 pacientes no se encontraron otras alteraciones. Conclusiones: El índice de apendicectomías no terapéuticas en nuestro hospital fue del 10,10% en el año 2013. La experiencia internacional y algunos trabajos nacionales demuestran que este resultado es mejorable. Se plantea la utilización de algoritmos clínicos para mejorar la presunción diagnóstica y hacer el mejor uso de los recursos diagnósticos disponibles, así como la instauración de un sistema de registro y análisis prospectivo de los resultados clínicos en apendicitis aguda.

Objectives: Acute appendicitis is one of the most frequent pediatric surgical diseases and appendectomy is a historically proved treatment. However, attention has been directed at morbidity and costs of negative appendectomy (NA). Here we analyze the incidence of NA at our hospital and its characteristics in order to propose a working hypothesis that allows a decrease in its incidence. Methods: A retrospective analysis including all patients who underwent surgery from 01/01/13 to 31/12/13, with presumptive clinical diagnosis of acute appendicitis, in the Pediatric Hospital of the Pereira Rossell Hospital Center, was done. Age, sex, surgical approach, operative findings, pathologic diagnosis and the use and results of laboratory and ultrasound, were analyzed. Results: In the referred period, appendectomies were performed in 287 patients with diagnosis of acute appendicitis, of which 146 (50.87%) were operated by a conventional approach and 141 (49.13%) by laparoscopic approach. The NA were 10.10%, with similar rates for both approaches (10.27% vs 9.92%, conventionalvs laparoscopic).A higher incidence of of NA was evident in girls, (16,6% vs 5,8% conventionalvs. laparoscopic ).With respect to the age group, the rate of NA was higher among 11-15 years old patients (12,19%), while for those aged between 6-10 years it was 8.08 % and for patients aged 0-5 years it was 4.16%. Of the 29 patients who had a healthy appendix, 12 had mesenteric adenitis, one patient had a follicular rupture and other had a medical peritonitis. In 15 patients no other abnormalities were found. Conclusions: The NA rate at our Hospital was 10.10% during 2013. The international experience and some national works prove that this result is improvable. We propose the utilization of clinical scores in order to improve clinical diagnostic and rational use of ancillary resources and the installation of a prospective registry and analysis system of results in acute appendicitis.

Objetivos: A apendicite aguda é uma das patologias cirúrgicas mais frequentes em pediatria e apendicectomia, um procedimento historicamente comprovado para seu tratamento. Entretanto, a atenção e a morbidade e os custos envolvidos em casos de apendicectomias não terapêuticas (ANT) chamaram a atenção. Realizamos um estudo para determinar a proporção de ANT em nosso hospital, analisamos suas características e propomos hipóteses de trabalho que nos permitem reduzir sua incidência. Métodos: Realizamos uma análise retrospectiva, incluindo todos os pacientes submetidos à cirurgia de 1/1/13 a 12/31/13 com diagnóstico clínico presumível de apendicite aguda no Hospital Pediátrico do Centro Hospitalar Pereira Rossell. Analisamos a idade, sexo, abordagem, achados intra-operatórios, diagnóstico anatomopatológico e o uso e resultados de hemograma e ultra-som. Resultados: no período mencionado, foram realizadas 287 apendicectomias em pacientes com apendicite aguda, dos quais 146 (50,87%) foram operados por abordagem convencional e 141 (49,13%) por abordagem laparoscópica. O índice ANT foi de 10,1% com taxas semelhantes para ambas as abordagens (10,27% versus 9,92% laparoscópicas). Por outro lado, houve maior incidência de ANT no sexo feminino (16,6% vs 5,8%). Em relação à faixa etária, a taxa de ANT foi maior entre os pacientes com idades entre 11-15 anos (12,19%), enquanto que para as idades 6-10 anos foi de 8,08% e para pacientes de 0 -5 anos foi de 4,16%. Dos 29 pacientes com apêndice saudável, 12 apresentavam adenite mesentérica, um paciente apresentava ruptura folicular e um paciente apresentava peritonite de grau médico. Não foram encontradas outras alterações em 15 pacientes. Conclusões: A taxa de apendicectomias não terapêuticas em nosso hospital foi de 10,10% no ano de 2013. A experiência internacional e alguns estudos nacionais mostram que esse resultado pode ser melhorado. O uso de algoritmos clínicos para melhorar a presunção diagnóstica e fazer o melhor uso dos recursos diagnósticos disponíveis, bem como o estabelecimento de um sistema de registro e análise prospectiva dos resultados clínicos em apendicite aguda.

Apendicectomías negativas y su relación con los estudios de imagen / Negative appendectomies and their relation with imaging studies

Objetivo: Identificar si los estudios de gabinete, como la tomografía axial computada y ultrasonido, se asocian con la menor incidencia de apendicectomías negativas. Sede: Hospital Christus Muguerza del Parque, Hospital Privado de Tercer Nivel. Diseño: Estudio de prueba diagnóstica, retrospectivo, descriptivo, observacional, transversal. Análisis estadístico: Sensibilidad, especificidad, valores predictivos y prueba de Bayes. Pacientes y métodos: Se incluyeron a todos los pacientes que fueron sometidos a apendicectomía durante el periodo entre enero 2006 a diciembre 2008. Se correlacionó el reporte histopatológico, como estándar de oro diagnóstico, con los estudios de gabinete realizados que consistieron en tomografía axial computada (TAC) y ultrasonido (US) en pacientes con cuadro clínico sugestivo de apendicitis aguda. Resultados: Se incluyeron 207 pacientes, de los cuales 107 fueron hombres (52%) y 100 mujeres (48%). En 183 pacientes (88.4%) sometidos a apendicectomía se confirmó el diagnóstico histopatológico de apendicitis aguda, mientras que los 24 pacientes restantes (11.6%) tuvieron apendicectomía negativa, de los cuales fueron 10 hombres y 14 mujeres. Durante el periodo estudiado, la frecuencia de apendicectomías negativas disminuyó un 66% en el 2008 respecto al 2007, al mismo tiempo que la utilización de TAC para evaluar estos casos aumentó un 41%. La TAC presentó una sensibilidad de 89%, especificidad de 60%, valor predictivo positivo (VPP) 94.8% y valor predictivo negativo (VPN) de 40%, la posibilidad post-prueba negativa (PPPN) fue de 59.9%. El US tuvo una sensibilidad de 63%, especificidad de 40%, VPP de 85.5% y VPN de 15.8%, y la PPPN fue de 84.2%. Conclusiones: El mayor empleo de la TAC abdominal con contraste IV, ni el ultrasonido, se asoció con una menor incidencia de apendicectomías negativas. El criterio clínico sigue siendo vigente.

Objective: To identify whether diagnostic imaging, such as computed axial tomography (CAT) and ultrasonography (US) can be associated with a lower incidence of negative appendectomies. Setting: Hospital Christus Muguerza del Parque, private third level health care hospital. Design: Diagnostic test, retrospective, descriptive, observational, cross-sectional study. Statistical analysis: Sensitivity, specificity, predictive values, and Bayesian testing. Patients and methods: All patients subjected to appendectomy in the period from January 2006 to December 2008 were included in the study. The histopathological report, as diagnostic gold standard, was correlated with the imaging studies, CAT und US, in patients with clinical symptoms suggestive of acute appendicitis. Results: We included 207 patients, 107 were men (52%) and 100 women (48%). In 183 patients (88.4%) subjected to appendectomy, the histopathological diagnosis of acute appendicitis was confirmed, whereas the remainder 24 patients (11.6%) had negative appendectomies, these corresponded to 10 men and 14 women. During the study period, the frequency of negative appendectomies decreased 66% in 2008 with respect to 2007, concurrently the use of CAT to assess these cases increased 41%. CAT presented a sensitivity of 89%, specificity of 60%, positive predictive value (PPV) of 94.8% and negative predictive value (NPV) of 40%, the possibility of negative post-test (PNPT) was of 59.9%. US had a sensitivity of 63%, specificity of 40%, PPV of 85.5% and NPV of 15.8%, and PNPT of 84.2%. Conclusions: Neither the increase in the use of CAT with IV contrast medium nor of US was associated with a lower incidence of negative appendectomies. The clinical criterion remains being valid.

Gynecologic pathologies in our appendectomy series and literature review / 대한외과학회지

PURPOSE: Appendectomy applied from the diagnosis of acute appendicitis is one the most common operations in surgery. The rates of negative appendectomy are still high. The rates of negative appendectomy in males and females differ and are higher in females. In our study, these differences, particularly in females, were studied and possible solutions were discussed. METHODS: Between October 2002 and October 2009, among women receiving urgent appendectomies, those whose primary cause was gynecological pathology were studied retrospectively. All our women subjects were examined by preoperative gynecologists. After gynecological consultation, the patients were evaluated by a general surgeon due to lack of urgent ultrasonography, computed tomography (CT) and diagnostic laparoscopy and the patient received appendectomy due to acute appendicitis. RESULTS: In our series of 1,969 appendectomies, the rate of female/male is 811/1,158. It was determined that the primary cause in 47 (47/811; 5.8%) women with applied appendectomy was gynecological pathology. As a gynecological pathology, it was observed that the most common cause was ovarian cyst ruptures at a rate of 72.3%. The negative appendectomy rate in males was found to be 14.94% (173/1,158), and in females it was 22.56% (183/811). The difference between them is significant (P < 0.01). Of these women, 5.8% were gynecologically-induced and 16.76% were unrelated to gynecological causes. CONCLUSION: We believe that gynecological consultation before appendectomy in women is necessary, but not sufficient. It is also important that at least one of the facilities, such as us, CT, magnetic resonance imaging, and diagnostic laparoscopy should be available in surgical use for the diagnosis of negative appendicitis.

The Role of Abdomen-pelvis CT for the Diagnosis of Appendicitis

PURPOSE: We wanted to evaluate the value of intravenous contrast enhanced abdomen-pelvis computed tomography (CT) for diagnosing acute appendicitis and we wanted to determine which patients groups will benefit from preoperative CT. METHODS: Between January and June 2006, the medical records of 354 patients who had clinically suspected acute appendicitis were retrospectively reviewed. Appendectomy was performed in 260 patients and CT was conducted in 108 patients of the 260 patients. The 5mm slice CT scans were evaluated for the presence of appendicitis. The sensitivity, specificity and accuracy of CT were calculated. The negative appendectomy rate (NAR) was compared between the patients with CT scans and those without CT scans. Furthermore, the patients were classified into the children and adults groups and the male and female groups and the differences of the NARs were analyzed for each group. RESULTS: The sensitivity, specificity and accuracy were 95%, 93% and 94%, respectively. The NAR was lower for the patients with a CT scan (12%) compared to 27% for those patients without CT scans (P=0.002). The difference of the NAR between the preoperative CT group and the without CT group was statistically significant for the female (P=0.004) and adult groups (P=0.012) (14% vs 36%, 11% vs 26%, respectively). CONCLUSION: Preoperative intravenous contrast enhanced abdomen-pelvis CT was effective in reducing the negative appendectomy rate in patients who were suspected of having acute appendicitis. Especially, the adults and women benefit more from CT scanning and they had a significantly lower negative appendectomy rate than the children and men, respectively.

The Impact of Appendiceal CT on Patients with Suggestive Appendicitis

PURPOSE: This study was performed to evaluate the contribution of appendiceal computed tomography (CT) in the more accurate diagnosis of acute appendicitis and decrease in the rate of negative appendectomies. METHODS: Between May and August 2005, 146 patients with right lower quadrant (RLQ) abdominal pain and tenderness were diagnosed using appendiceal CT. The appendiceal CT scans were performed with contrast media in the abdominal and pelvic areas. 7 mm slice scans were taken both before and after the contrast media injection, with a time delay. The control group was comprised of 99 patients, who were also checked by abdominal CT or ultrasonography, between December 2004 and April 2005, with the data analyzed retrospectively. RESULTS: In the study group, 85 of the 146 cases were diagnosed with acute appendicitis on appendiceal CT, and had undergone an appendectomy, including 42 men (mean age 39.9 yr) and 43 women (mean age 44.6 yr). The sensitivity and specificity of appendiceal CT in acute appendicitis were 95.3 and 98.4%, respectively. There were 4 (4.7%) negative appendectomy cases; 2 in men and 2 in women. The control group conprised of 47 men and 52 women. There were 13 (13.1%) negative appendectomy cases; 4 in men and 9 in women. CONCLUSION: The routine use of appendiceal CT, in patients with RLQ abdominal pain and tenderness, resulted in a significant decrease in the negative appendectomy rate.

Comparison of Computer Tomography and Sonography in Patients Suspected of Having Appendicitis

BACKGROUND: This study was conducted to compare the accuracy of computered tomography(CT) and sonography(US) in diagnosing acute appendicitis and to analyze the radiologic factors which influence the result. METHODS: We retrospectively studied the cases of 53 patients who were suspected of having appendicitis and who were examined by CT and US covered a three-year period. The final diagnosis was determined from the surgico-pathologic diagnosis and clinical follow-up for two months, as well as from the discharge diagnosis. RESULTS: Thirty-eight(38) patients had acute appendicitis; 15 patients did not. In the analysis, CT and US, respectively, revealed sensitivities of 89.5% and 73.7%, specificities of 93.3% and 60.0%, positive predictive values of 97.1% and 82.4%, negative predictive values of 77.8% and 47.4%. Among patients diagnosed with acute appendicitis, 10 patients were discordant in the US and the CT examinations; CT findings were correct in 8 and US findings in 2. Among non-appendicitis patients, 5 patients were discordant in the US and the CT examinations; CT was correct in 5 and US in 0. Nighteen(19) patients had complications such as an abscess or a perforation. Among these patients, the degree and the extent of the complication were accurately evaluated by CT in 15 patients and by US in 5 patients. CONCLUSION: CT is more accurate than US in diagnosing and excluding acute appendicitis. The use of CT will substantially decrease unnecessary laparotomies and post-operation complications.

A Comparative Study of the Clinical Features between Negative Appendectomy and Conservative Treatment Groups in Suspected Appendicitis

This study is a clinical review of two groups of patients. Group I was composed of 97 patients who were submitted to negative appendectomy under the impression of acute appendicitis and, group II was 45 patients who received conservative treatment with the same impression at the department of surgery, Dae Rim Saint Mary's Hospital, from January 1, 1994 to August 31, 1996.The purpose of this study is to identify possible factors for the decision of operation or conservative treatment in the patients with suspected appendicitis and so to decrease unnecessary operation. Clinical characteristics of the patients were compared between two groups by the method of comparison of means(X test). The following results were obtained; 1) The incidences of group I and group II among the patients in the state of suspicious appendicitis were 97 of 1,004 cases(9.7%) and 45 of 1,004 cases(4.5%) respectively. 2) The number of female patients was 1.5 times more than male in both groups(p0.05) 8) Leukocytosis above 10,000/mm3 appeared in 44% of patients in group I and 53.3% in group II(p>0.05). 9) In admission route, the patients via ER was 2 times more than those of OPD in group I and in group II that was 5 times more than this.

Clinical Evaluation about RLQ Pain Seconary to Chronic Constipation (or Fecal Impaction): About DDx from caute appendicitis

There are many causes of the right lower quadrant(RLQ) abdominal pain. Although the most common underlying cause may be acute appendicitis, chronic constipation(or fecal impaction) is the cause in some portions. In review of 120 patients with chronic constipation between 1990 and 1996, we evaluated the clinical characteristics of the RLQ pain secondary to chronic constipation. In case of the RLQ pain secondary to chronic constipation, the key points in the DDx from the RLQ pain due to acute appendicitis are as follows. (1) RLQ pain in chronic constipation is characterized by dull pain and usually it has been complained for several weeks, several months or even several years in more than half. (2) The patients don't have accompanying G-I symptoms(such as anorexia, nausea, vomiting, and epigastric pain) in more than 90%. (3) The patient complains of mild tenderness in RLQ area in some cases but no rebound tenderness was found in any cases. (4) In almost all cases, WBC count in patient's blood is within normal limits and body temperature is under 37.0degrees C. (5) For the most part, simple abdomen X-ray finding shows large or moderate amount of fecal material in the colon. So I suggest that (a) DDx in the RLQ pain could be made between acute appendicitis & chronic constipation by above findings and (b) In case of chronic constipation we need not perform negative appendectomy and it could be managed by conservative management such as enema, laxatives, high fiber diet, etc. Conclusively, I mention that the rate of negative appendectomy would be able to be reduced a little by taking these points into consideration in the clinic.